Suicide related to the COVID-19 pandemic in India: A systematic review

Background The suicide rate has increased during the pandemic in India. Moreover, several studies, especially press-media reporting suicide studies have been conducted but no systematic review has been attempted in this context. Therefore, the present study systematically investigated the risk factors associated with suicidal behaviors, and the method of suicide during the COVID-19 pandemic in India. Methods Following the PRISMA guidelines, a systematic search was performed to include papers published up until September 30, 2022. From an initial 144 papers, 18 studies which met the inclusion criteria were included in the present review. The Pierson’s method was used for quality assessment of the included studies in the present review. Results The risk factors associated with suicide comprised: (i) socio-demographic factors (e.g., being aged between 31 and 50 years, male, married, unemployed), (ii) behavior and health-related factors (e.g., unavailability of alcohol and alcohol withdrawal symptoms, poor state of physical health and health issues, family disputes, relationship complexities, and sexual harassment), (iii) COVID-19-related factors (e.g., fear of COVID-19, COVID-19 test results, quarantine or isolation, financial hardship due to the pandemic, having influenza-like symptoms, experiencing stigmatization and ostracism despite testing negative, separation from family due to transport restrictions, misinterpreting other illness symptoms as COVID-19, saving the village from infection, watching COVID-19 videos on social media, online schooling, perceived stigma toward COVID-19, and being suspected of having COVID-19), and (iv) psychopathological stressors (depression, loneliness, stress, TikTok addiction, and poor mental health, suicidal tendencies, helplessness, and worrying). Hanging was the most common method of suicide. In addition, jumping from high buildings, poisoning, drowning, burning, cutting or slitting throat or wrists, self-immolation, medication overdose, electrocution, pesticide, and gun-shot were also used to carry out the suicide. Conclusions Findings from this research suggest multiple reasons for suicide during the COVID-19 pandemic and knowledge of such factors could aid in developing suicide prevention strategies focusing the most vulnerable cohorts inside and outside India.


Introduction
Suicide is a major multifactorial phenomenon, which includes diverse factors that result in death by suicide. More than 20 suicide attempts are typically reported before a successful suicide attempt (i.e., suicide completion) [1]. Low and middle-income countries like India have been reported to have approximately 80% of the global suicide occurrences [2]. Additionally, the suicide rate in India has been increasing based on the National Crime Records Bureau (NCRB) data [3]. For instance, a report showed that more than 139,000 suicides in India were recorded in 2019 with a 3.4% increase compared to 2018 (134,516 suicides) which was higher than 2017 (129,123 suicides) [3]. In addition, statistics have shown that there were more than 380 daily suicide cases in India in 2019 [3]. Given the increasing numbers of suicides, the incidence rate may also rise during stressful situations such as the COVID-19 pandemic.
During the COVID-19 pandemic, individuals have reported to be suffering psychologically due to lockdown-related stressors such as fear and panic, frustration, scarcity of basic supplies, the authenticity of reliable information, perceived stigma, financial distress, and lack of physical exercise [4][5][6][7][8][9]. Such factors heighten the chances of suicide and suicidal behaviors [10]. In prior outbreaks, suicide has been reported to increase because of these stressors. Some of the studies claimed that the suicide rate increased during the COVID-19 pandemic due to unemployment. India has already reported severe economic disruption due to the pandemic [11]. Given the situation that the country has already experienced, the second wave of the pandemic intensified the problems. For instance, an Indian study claimed suicide had increased during the pandemic based on press media reports [12]. However, evidence utilizing data from other countries' national suicide databases did not find an increase in suicide rate in 21 countries [13].
On 12 February 2020, Goyal et al. [14] reported the first Indian suicide case related to the COVID-19 pandemic. A 50-year-old man died by hanging on a tree, where the fear of COVID-19 infection was alleged to be the suicide stressor. The victim was reported being constantly obsessed with the videos of the Chinese suspected patients' forcefully being placed into healthcare settings for quarantine against their will. He reported experiencing flu-like symptoms to a physician, which resulted in disturbed thinking concerning the protection of his family. He ended up quarantining himself, and the fear and panic of acquiring COVID-19 appeared to have been the main reasons to end his life [14]. One month after this case was reported, another study investigated a total of 69 Indian suicide cases between March to May 2020 and reported that fear of COVID-19 appeared to be the most significant suicide attributor [15]. Given the unprecedented situation, a number of studies have continued to investigate COVID-19 related suicide in India. However, to the best of the present authors' knowledge, there has been no integration of the findings of these studies. Therefore, the present review explored the stressors that lead to suicide, and the methods used to commit suicide among Indian individuals during the COVID-19 pandemic.

Search strategy
To conduct the present a systematic review, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed [16]. First, a systematic literature search was performed using PubMed, Scopus, and EuroPMC to retrieve Indian suicide studies related to the COVID-19 pandemic. Additional searches were conducted using Google Scholar, and ResearchGate to collect the preprints. Search keywords included: press-media reporting suicide, press-media suicide, media suicide, press-report suicide, COVID-19 suicide India, pandemic suicide India. These were combined following the Boolean operator (OR, AND, NOT).

Study selection criteria
First, the titles and abstracts of each paper were examined. Then the available full-text papers were assessed based on the inclusion criteria. The inclusion criteria were (i) being a study conducted in India, (ii) reporting a single case or case series, (iii) being published since the start of the pandemic to September 30, 2022, (iv) being either related to suicide case(s) or suicide behaviors (i.e., suicidal ideation, suicide plan, and suicide attempt), (v) reporting stressors

Suicide stressors
All studies reported suicide reasons or stressors. These were classed into four categories: (i) socio-demographic stressors, (ii) behavior and health-related stressors, (iii) COVID-19 related stressors, and (iv) psychopathological stressors.

Socio-demographic stressors
Only three studies recorded the socio-demographic factors as reasons for suicide [12,21,27]. A study that reviewed media reports from March 24 to May 3 2019 and March 24 to May 3 2020 reported 157 COVID-19-related suicides (128 completed suicides and 29 suicide attempts) aged 31 to 50 years. Of the 157 cases, 73 were male, 41 were married, and 86 were employed [12]. Unemployment appeared to be a key suicidal stressor in two (out of seven) cases of celebrity suicide [21]. Sudden unemployment in one migrant worker was found to be a stressor leading to suicide in a study of 23 cases [27].

Alcohol
A total of six studies reported alcohol-related suicide during the pandemic [15,18,19,26,27,30]. Two of the studies included all of the suicide cases having alcohol-related issues [i.e. 27 cases reported by Syed and Griffiths [30] and 23 cases reported by Ahmed et al. [18]. Here all cases were due to alcohol withdrawal symptom-related stress. In the other four studies, 3/69 cases by Dsouza et al. [15], 5/144 cases by Panigrahi et al. [26], 28/370 cases by Balaji and Patel [19], and 3/23 cases by Rajkumar [27] reported the unavailability of alcohol and/or alcohol addiction as the suicide stressors.

Physical health
Physical health problems were reported to be a suicide stressor in two studies [12,22]. A study comparing suicide cases in 2019 with 2020 found more physical health issues among individuals who died by suicide during the pandemic [12]. In addition, health issues were also recorded as stressors leading to suicide in 32/194 cases during the pre-lockdown period and 75/373 during the lockdown, in a press-media reporting study [22]. However, this latter study showed no significant difference between suicide pre-lockdown and during the lockdown.

COVID-19 test results COVID-19 test results also appeared to have influenced suicide. Several studies identified
COVID-19 positive test results as a cause of suicide [15,[26][27][28][29] whereas Panigrahi et al. [26] reported that an individual being advised to take a COVID-19 test was a stressor that led to suicide [33.7% (51 out of 151)]. One individual who had negative COVID-19 results was reported to have died by suicide due to stigmatization and ostracism by the local community [27]. Two individuals were reported to have died by suicide due to anxiety following positive COVID-19 test results [28].

Quarantine/isolation
The COVID-19 quarantine/isolation period appeared to have a negative impact on individuals, which in turn can trigger suicide. Four studies reported that quarantine or isolation played a role in individuals' suicides: being pressured or being afraid to be quarantined (6/69) and two died by suicide at quarantined centers (2/69) [15]; depression during quarantine (1/11) [25]; being quarantined or isolated (74/143) [26]; and among the 157 individuals reported by Pathare et al. [12] some died due to being quarantined (although the exact numbers were not reported).  [19], and 3/7 cerebrities by Kar et al. [21].

Stress
Three studies reported that work-related stress was a factor leading to suicide (3/69 by Dsouza et al. [15], 1/23 by Rajkumar [27], and 2/8 health workers by Jahan et al. [20]). Other studies found that some individuals were stressed due to flu-like symptoms committed suicide: 7/23 by Rajkumar [27] and 71/143 by Panigrahi et al. [26]. A total of three individuals died by suicide due to stress related to online schooling [25]. However, one case had had pre-existing family-related issues and one case had stress that led to death by suicide [25].

Miscellaneous
Other suicide-related stressors have been reported during the pandemic including poor mental health (one reported by Jahan et al. [20] and 18/369 by Pathare et al. [12]). One media case study also reported feelings of helplessness and worrying as causes of suicide [31].

Burning and self-immolation
Burning oneself was reported to be a method of suicide in six studies [22-24, 26, 28]. A total of 57 individuals used this method of suicide during the pandemic. Self-immolation was reported in one study (n = 11/370) [19].

Methods of attempting suicide
Two studies reported the methods used in attempted suicide [12,30]. These methods included hanging [ [12]. Jumping from a building was reported in one case [30].

Discussion
The present systematic review was conducted to explore the stressors that lead to suicide and the methods used to die by suicide among the Indian population during the COVID-19 pandemic. Several studies have been conducted that have examined pandemic suicide in India, but to understand the overall scenario, a more systematic approach was needed. In India, males were found to die by suicide more than females during the pandemic. Previous studies have reported a similar finding. For instance, a global English newspaper review of 18 cases between January 1 to April 30, 2020 (15 suicides, two suicide attempts, and one homicide-suicide) reported 17 were males [32]. Similarly, media report studies from Bangladesh and Uganda have reported a higher number of males committing suicide compared to females [33][34][35][36]. Males appear to be more likely to die by suicide in the current pandemic. Traditional social factors such as the need to appear masculine may be an obstacle to sharing their feelings and seeking support, increasing the risk of suicide. Therefore, there is a need for emotional and mental health support for men to improve their mental health to reduce the suicide rate.
In addition, unemployment status and abrupt job loss were also found to be suicide stressors. Similarly, in Bangladesh a study reported lockdown-related financial recession as the most prominent factor of suicide during the early period of the pandemic [33]. Another study reported that poverty was one of the contributing factors for individuals dying by suicide [35]. In addition, a longitudinal study covering 63 countries explored the relationship between suicide and unemployment, estimated a 20%-30% increase in unemployment-associated suicide rate over a 12-year period (2000-2011) [37]. Given this unprecedented situation, some preventive measures such as financial safety nets including food, housing, loans, and additional focus on active labour market programs, might effectively reduce suicide-related to financial conditions [38].
Unavailability of alcohol and/or withdrawal of alcohol symptoms and poor physical health were significantly reported as stressors leading to suicide. Alcohol consumption in India has increased over the past few years [39]. More specifically, approximately 5.4 billion litres of alcohol were consumed in India in 2016, whereas it was 6.5 billion litres in 2020 [39]. This means that Indian individuals are drinking alcohol more frequently than in the past. Therefore, not being able to access alcohol because of countrywide lockdown-related factors appears to have triggered suicide in extreme cases. One study in India reported 27 cases of suicide, in which 26 cases completed the suicide due to the fact they could not cope with alcohol withdrawal symptoms [30]. To prevent this kind of unnecessary death, the government (as well as non-governmental organizations) may attempt to adopt preventive strategies such as monitoring alcohol intake, spreading safe drinking messages, providing access to safe drinking, and disseminating crisis resource messages organizations [40]. However, individuals with physical medical conditions are at a greater risk of suicide than those who are not. Similar findings have also been reported in previous studies. For instance, a census-based follow-up study of over one million individuals found that individuals with a lot of physical medical conditions were at a three-fold greater risk of suicide than those who had no limitations in their physical activity [41]. Another study among the US general public found that multiple physical conditions such as traumatic brain injury, sleep disorders, and HIV/AIDS significantly exacerbated suicide risk [42].
The first case of COVID-19 suicide in India reported fear of COVID-19 as a significant factor [9]. Similarly, in a neighbouring country (i.e. Bangladesh), fear was also reported as a stressor of the first case of COVID-19-related suicide [43]. This finding suggests that fear is the most reported factor for dying by suicide among individuals. A press-reporting media study comprising 69 Indian reports concluded that fear of COVID-19 was the most prominent risk factor for suicide [15]. Individuals who suspect they have COVID-19 and those advised to test for COVID-19 have also been reported as reasons for suicide. For instance, one study indicated that half of the Indian suicide cases emerged within one week of COVID-19 diagnosis confirmation, and half of the suicides occurred at COVID-19 centres [29]. Therefore, counselling, raising awareness, and campaigning should be given the highest priority to combat such suicides.
Quarantining and isolating are considered primary level measures to combat COVID-19. A previous study showed its effectiveness during the COVID-19 pandemic. For example, non-quarantining communities showed an incidence and death rate of 96% and 76%, whereas after adhering to quarantine measures, the rate diminished to 44% and 31% [44]. However, studies have also shown the negative impact of mass quarantine or isolation among individuals, reporting it as a risk factor for suicide [33,35]. However, a study among US adults found no associations between physical distancing and increased suicidal behaviors during the pandemic [45]. It is anticipated that suicide incidence might be (in part) due to social disconnection. Therefore, telecommunication and social connection might reduce the rate of suicide in this context. Other stressors related to COVID-19 include family disputes, watching COVID-19 videos on social media, online schooling, and relationship complexities or issues. Online schooling-related suicide has also been reported in other countries. A mother-son suicide pact was reported as an online learning issue during the pandemic [6].
It is well-established that psychological suffering (i.e., depression, anxiety, stress, loneliness, insomnia, etc.) can lead to suicide in extreme cases. Moreover, approximately 90% of individuals who die by suicide have a mental health disorder. The present findings also supported this. The present study reported depression, loneliness, stress, TikTok addiction, and poor mental health as suicide stressors that intensified suicidal ideation. A recent systematic review found suicidal ideation prevalence rate ranging from 5% to 19%, where depression, anxiety, stress, insomnia, suicidal thoughts history, suicide attempt history, and family history of committing suicide were the major attributors to suicidal behaviour [10]. Therefore, mental health symptoms may play a significant role in suicide, and intervention to relieve mental health symptoms are vital during the pandemic to reduce suicide.
Although hanging was the most preferred method of suicide, individuals also died by suicide by poisoning, jumping off or into something, burning, slitting throat or cutting wrists, drowning, medical overdose, and gunshot. A 5-year study from one of the largest cities of India recruiting over 5000 cases reported different method of suicide among the victims. They found poisoning as the most common method of suicide among males followed by hanging, firearms, burns, drowning, and jumping from a height, whereas for females, it was also poisoning followed by hanging, burns, drowning, jumping from a height, and firearms [46].

Limitations
The present study has a number of limitations. First, the data comprised only cases from media reports, and some of the suicide reports might have been used in multiple studies which means the numbers of cases may not be as accurate as they could be and may lead to overestimated figures concerning suicide stressors or methods of suicide. Second, with often limited information provided by the media case report, sophisticated analysis is almost impossible. Third, information reported by media in the included studies may be biased and/or simplistic because none of the reported studies performed psychological autopsies. In addition, the suicide data extraction from the media reports may be biased or subjective due to the suicide expertise of the authors involved in the respective studies. Finally, due to some media stories adhering to the reporting guidelines for suicide as provided by the World Health Organization may also have led to omission of some important information (details about stressors or methods, for example) that provide additional insight into suicide during the pandemic.

Conclusions
Suicide is of serious concern during the current pandemic situation, and reducing it is a significant challenge for a country such as India, where more than 380 individuals have died daily due to suicide during the pandemic. Findings from the study demonstrated the method and alleged risk factors of suicide in a developing country during the COVID-19 pandemic. Findings from this research suggest multiple reasons for suicide during the pandemic and knowledge of such factors could aid in developing suicide prevention strategies focusing the most vulnerable cohorts inside and outside India. Further study is suggested to conduct observational studies using a quantitative approach to explain the risk factors of suicide rather than a qualitative approach.